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RETURN FORM TO: <br />Board of Public Works <br />1316 County-City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 ● Fax: (574) 235 -9171 <br />2 <br />This Agreement is subject to revocation by the City of South Bend if this lot(s) is/are <br />offered for sale prior to . <br />Date: <br />Company Representative <br />Signature: <br />Name: Telephone: <br />Title: <br />Address: <br />City: State: Zip: <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />Member Member Date